Full Name
First Name
Last Name
Gender
*
Residential Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Postal Address, if different to the above
Date of Birth
MM
DD
YYYY
Place of Birth
Mobile Number
Email Address
What is your NSW Competency Card Number? It starts with the letters "CCH".
Disqualification & Discipline
*
Have you ever been the subject matter of an investigation, prosecution, official warning issued by the NSW Police, or been refused, suspended or disqualified from holding a liquor licence or gaming licence in Australia, or been the subject matter of any disciplinary action under the liquor and gaming laws anywhere in Australia?
Prescribed Offence
*
In the last 3 years have you committed a prescribed offence? “Prescribed offence” is not currently defined in the 2007 Liquor Act, however the Act previously noted a prescribed offence for an individual when:
• a court convicts the person of an offence (whether or not it imposes any penalty), or
• an amount is paid under a penalty notice in respect of an offence, or
• a penalty notice enforcement order under the Fines Act 1996 is made against the person in respect of the offence.
Prescribed offence includes offences relating to licensed premises like supply liquor contrary to conditions, permitting intoxication or indecent, violent or quarrelsome conduct, sale liquor to a minor etc.
Criminal Offences
*
Have you ever been charged with a criminal offence in the last 10 years, or do you have any pending criminal charges against you?
Liquor Licence
*
Are you still associated with a liquor licence, as a current licensee?
If your "approved manager" application is granted by the L&GNSW, what is the name and address of the licensed premises you will manage?
Payment of Application
The lodgement fee payable to the L&GNSW is $125.00. This amount must be paid by the use of a credit card. Please provide your credit card number, the type of card [i.e. visa] and its expiry date below. Please also provide the CVN number at the back of the card
Declaration
*
Please confirm you agree to the following:-
• I declare that I am 18 years or older.
• I declare that all information provided to BSV is true and correct.
• I agree to immediately notify L&GNSW of any change to the information in this application before the application is determined.
• I acknowledge that under section 36 of the Gaming and Liquor Administration Act 2007 and section 307A of the Crimes Act 1900 it is an offence to provide false, misleading or incomplete information in this application.
• I acknowledge that failure to provide all required information may result in delay, withdrawal or refusal of my application.
• I understand that specific details I have supplied in this application may be ‘personal information’ under the Privacy and Personal Information Protection Act 1998. Personal information is any information or opinion that identifies an individual, or enables someone to identify an individual.
• I acknowledge that L&GNSW is collecting information on behalf of the Independent Liquor & Gaming Authority (ILGA) to enable processing of the application.
• I also understand that L&GNSW will use this information for its intended purpose only, store the information securely, and allow the applicant or licensee to access and update the information. When processing this application, L&GNSW may need to disclose information to other Government agencies.
